In a democratic society, the stronger and broader the support for a public health initiative, the greater its chance for success. The social and political will can be mobilized when it is believed that suicide is preventable. If the general public understands that suicide and suicidal behaviors can be prevented, and people are made aware of the roles individuals and groups can play in prevention, many lives can be saved.
In order to mobilize social and political will, it is important to first dispel the myths that surround suicide. Many of these myths relate to the causes of suicide, the reasons for suicide, the types of individuals who contemplate suicide, and the consequences associated with suicidal ideation and attempts. Better awareness that suicide is a serious public health problem results in knowledge change, which then influences beliefs and behaviors (Satcher, 1999). Increased awareness coupled with the dispelling of myths about suicide and suicide prevention will result in a decrease in the stigma associated with suicide and life-threatening behaviors. An informed public awareness coupled with a social strategy and focused public will lead to a change in the public policy about the importance of investing in suicide prevention efforts at the local, State, regional, and national level (Mrazek & Haggerty, 1994).
Background Information and Current Status
The factors that contribute to the development, maintenance, and exacerbation of suicidal behaviors are now better understood from a public health perspective (Silverman & Maris, 1995). A public health approach allows suicide to be seen as a preventable problem, because it offers a way of understanding pathways to self-injury that lend themselves to the development of testable preventive interventions (Gordon, 1983; Potter, Powell & Kachur, 1995). Although some have criticized the public health model of suicide as being too disease-oriented, it does, in fact, take into account psychological, emotional, cognitive, and social factors that have been shown to contribute to suicidal behaviors (Potter, Rosenberg, & Hammond, 1998).
Did You Know?
In the 10 years 1989-1998, 307,973 people died as a result of suicide.
Suicide is a major public health problem. It is one of the top ten leading causes of death in the United States, ranking 8th or 9th for the last few decades. For the approximately 31,000 suicide deaths per year, there are an estimated 200,000 additional individuals who will be affected by the loss of a loved one or acquaintance by suicide. The economic and emotional toll on the Nation is profound (Palmer, Revicki, Halpern, & Hatziandreu, 1995).
How Will the Objective Facilitate Achievement of the Goal?
The objectives established for this goal are focused on increasing the degree of cooperation and collaboration between and among public and private entities that have made a commitment to public awareness of suicide and suicide prevention. To accomplish this goal, support for innovative techniques and approaches is needed to get the message out, as well as support for the organizations and institutions involved.
Objective 1.1: By 2005, increase the number of States in which public information campaigns designed to increase public knowledge of suicide prevention reach at least 50 percent of the State’s population.
Suicide has been designated as a serious public health problem by the U.S. Surgeon General, and the 105th U.S. Congress has recognized that this problem deserves increased attention [U.S. Senate Resolution 84 (5/6/97) and U.S. House Resolution 212 (10/9/98)]. They recognize suicide as a national problem and declare suicide prevention as a national priority, encouraging the development of an effective national strategy for the prevention of suicide. Public and private organizations have developed information campaigns to educate the public that suicide is preventable, as it can be a consequence of other treatable disorders such as depression, schizophrenia, bipolar illness, alcohol and drug abuse, and certain medical conditions. Campaigns alert professional, community, and lay groups about the common signs and symptoms associated with suicidal behavior. Some organizations with existing campaigns include the American Association of Suicidology (AAS), the American Foundation for Suicide Prevention (AFSP), the Suicide AwarenessVoices of Education (SAVE), the Suicide Prevention Advocacy Network (SPAN USA), and Yellow Ribbon Suicide Prevention Program.
Ideas for Action
Work with local media to develop and disseminate public service announcements describing a safe and effective message about suicide and its prevention.
Public information campaigns can take many forms. No single slogan or message works for everyone. For example, the primary purpose of the annual National Depression Screening Day is to identify, in a variety of settings, individuals with symptoms of depression and refer them for treatment (Jacobs, 1999b). However, such a screening program performed at primary care centers, mental health and substance abuse treatment centers, colleges, universities, and places of employment can play an important role in raising awareness and educating large groups of individuals about this mental disorder and its association with suicidal behaviors. Because no one is immune to suicide the challenge is to develop a variety of messages targeting the young and the old, various racial and ethnic populations, individuals of various faiths, those of different sexual orientations, and people from diverse socioeconomic groups and geographical regions.
Objective 1.2: By 2005, establish regular national congresses on suicide prevention designed to foster collaboration with stakeholders on prevention strategies across disciplines and with the public.
Broad-based participation and involvement is needed to ensure progress in reducing the toll of suicide. Open discussion and assessment of suicide prevention programs can only lead to their refinement and better chances for success.
The techniques and tools to create and implement prevention initiatives can be taught and demonstrated. Learning how to develop and disseminate public health messages and to mount public health campaigns is critical to implementing suicide prevention efforts.
A number of organizations have convened annual, national meetings devoted to suicide prevention. Currently, such meetings are sponsored by AAS, AFSP, and biennially by the International Association for Suicide Prevention (IASP). The establishment of regular national congresses on suicide prevention, collaboratively sponsored by more than one organization, will maintain interest and focus on this issue. Ideally, these national congresses should be sponsored by public/private partnerships (see Objective 2.2), and focus on needs and plans for coordinating effective suicide prevention efforts.
Ideas for Action
Identify foundations and other stakeholders to contribute to the support of national congresses on suicide prevention.
Objective 1.3: By 2005, convene national forums to focus on issues likely to strongly influence the effectiveness of suicide prevention messages.
National forums increase awareness of the problem of suicide and serve to mobilize social will. Such meetings keep the subject in the forefront of attention and raise concerns to the national level. Such activities increase connectedness between and among key stakeholders, and serve to bring support, consensus and collaboration to suicide prevention efforts.
Focusing on factors that influence the effectiveness of suicide prevention initiatives is critical to an overall strategy. National forums are opportunities to focus on specific issues that affect all efforts to mount suicide prevention initiatives. By highlighting specific areas, consensus can be reached on how best to incorporate elements into a suicide prevention plan and how best to evaluate effectiveness.
Ideas for Action
Incorporate suicide awareness and prevention messages into employee assistance program activities in businesses with greater than 500 employees.
Objective 1.4: By 2005, increase the number of both public and private institutions active in suicide prevention that are involved in collaborative
The World Wide Web offers an unparalleled opportunity to bring public health information to a much broader audience because it can be accessed at home, at work, at schools, at community centers, at libraries, or at any other location where there is access to the Internet. Not only does the World Wide Web offer exciting possibilities for the delivery of public health messages (including promoting awareness and referral sources for those in need), but it offers an opportunity to develop preventive interventions as well.
For example, the World Wide Web offers the potential for interactive dialogue and exchange of accurate information. Clear, concise, and culturally sensitive public health messages are key to assisting individuals to evaluate their at-risk status accurately and to know where and how to get help. It therefore is important that both public and private institutions committed to suicide prevention activities collaborate and cooperate to deliver information that is consistent, comparable, complementary, and not competitive. In addition to several Federal websites (see Appendix D), some of the key national organizations currently disseminating suicide prevention information on the World Wide Web include AAS, AFSP, IASP, SPAN USA, and the American Academy of Pediatrics.
Did You Know?
Suicide is the eighth leading cause of death for all Americans.
GOAL 3:
Develop and Implement Strategies to Reduce
the Stigma Associated with Being a Consumer
of Mental Health, Substance Abuse, and Suicide
Prevention Services
Why is this Goal Important to the National Strategy?
Suicide is closely linked to mental illness and substance abuse and effective treatments exist for both. In fact, 60 to 90 percent of all suicidal behaviors are associated with some form of mental illness and/or substance use disorder (Harris & Barraclough, 1997). Despite the fact that effective treatments exist for these disorders and conditions, the stigma of mental illness and substance abuse prevents many persons from seeking assistance; they fear prejudice and discrimination. About two thirds of people with mental disorders do not seek treatment (Kessler et al.,1996). The stigma of suicide, while deterring some from attempting suicide, is also a barrier to treatment for many persons who have suicidal thoughts or who have attempted suicide.
People who have a substance use disorder also face stigma, because many people believe that abuse and addiction are moral failings and that individuals are fully capable of controlling these behaviors (Murphy, 1992). Rather, many mental health professionals, consider mental disorders, alcohol abuse, and drug abuse disorders not as signs of weakness, but as disorders that require professional assessment and clinically appropriate treatment (U.S. Department of Health and Human Services, 1999).
While the stigma attached to mental illness and addiction prevents persons at risk of suicide from seeking help for treatable problems, the stigma of suicide itself may also reduce the number of people who seek help, while adding to emotional burdens. Family members of suicide attempters often hide the behavior from friends and relatives, since they may believe that it reflects badly on their own relationship with the suicide attempter or that suicidal behavior itself is shameful or sinful. Persons who attempt suicide may have many of these same feelings. Those who have survived the suicide of a loved one suffer not only the grief of loss, but the pain of isolation from a community that may be perplexed and uninformed about suicide and its risk factors.
Historically, the stigma associated with mental illness, substance use disorders and suicide has contributed to the inadequate funding available for preventive services and to low insurance reimbursements for treatments. Until the stigma is reduced, treatable substance use and mental health problems–including those strongly correlated with suicide– will continue to go untreated, and services tailored to persons in crisis will continue to be limited. As a result, the number of individuals at risk for suicide and suicidal behavior will remain unnecessarily high.
Background Information and Current Status
Stigma has been identified as the most formidable obstacle to future progress in the arena of mental health (U.S. Dept. of Health and Human Services, 1999). It is a key reason that certain ethnic groups are particularly disinclined to seek treatment for mental illness or substance abuse (Sussman et al., 1987; Uba, 1994). Stigma is intense in rural areas (Hoyt et al., 1997) and it is implicated in the low percentages of youth and the elderly with mental disorders–both groups at high risk for suicidal behavior– who receive mental health services (Kazdin et al., 1997; U.S. Department of Health and Human Services, 1999).
Over the past 25 years, a principal goal shared by mental health consumer and family advocacy groups is to overcome the stigma of mental illness. These groups include The National Alliance on Mental Illness and the National Mental Health Association. Other mental health advocates, such as the American Psychological Association and the American Psychiatric Association, have also worked to reduce stigma. The publication of Mental Health: A Report of the Surgeon General represents a milestone in the Federal government’s effort to reduce stigma by dispelling myths about mental illness and by providing accurate knowledge.
How Will the Objectives Facilitate Achievement of the Goal?
The objectives established for this goal are designed to create the conditions that enable persons in need of mental health and substance abuse services to receive them. There are many reasons why individuals may not receive such services, but stigma is an important factor. Stigma dissuades people from seeking mental health or substance abuse services.
It is both a contributing cause and a result of society’s collective devaluation of mental and substance abuse illness as compared to physical illness, such as heart disease or diabetes. The stigma of mental illness and substance abuse has resulted in the establishment of separate systems for physical health and mental health care; one consequence is that preventive services and treatment for mental illness and substance abuse are much less available than for other health problems. Moreover, this separation has led to bureaucratic and institutional barriers between the two systems that complicate the provision of services and further impede access to care. Destigmatizing mental illness and substance abuse could increase access to treatment by reducing financial barriers, integrating care, and increasing the willingness of individuals to seek treatment.
Did You Know?
Suicide has ranked among the 10 leading causes of death since 1975.
Objective 3.1: By 2005, increase the proportion of the public that views mental and physical health as equal and inseparable components of overall health.
Due to the historic bias and prejudice against those with mental illnesses, health care, mental health care, and substance abuse treatment have traditionally been viewed as separate types of treatment; persons who need mental health care or substance abuse treatment avoid seeking it, and insurance companies often do not pay for it. As our Nation moves towards viewing mental illness and substance abuse disorders with the same concern and understanding as it views other illnesses, there will be a concomitant change in the importance attached to effective and available care, along with increased political support for “parity” (the financing of mental health care and substance abuse treatment on the same basis as that of other health services).
Ideas for Action
Review (and modify, where indicated) school health curricula to ensure that mental health and substance abuse is appropriately addressed.
Objective 3.2: By 2005, increase the proportion of the public that views mental disorders as real illnesses that respond to specific treatments.
Behavior associated with mental disorders is still viewed by many persons as evidence of a character flaw rather than an illness. Consequently, disease that is treatable remains untreated because it is not perceived as disease. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate; more persons will seek treatment and the suicide rate will be reduced.
Ideas for Action
Develop public service announcements in which well-known individuals convincingly portray the effectiveness of treatment for mental illnesses and substance use disorders.
Support an educational campaign designed to help the public understand the implications of the brain research conducted over the past decade, with special emphasis on mental illness.
Objective 3.3: By 2005, increase the proportion of the public that views consumers of mental health, substance abuse, and suicide prevention services as pursuing fundamental care and treatment for overall health.
When the act of seeking services for mental health concerns is normalized, and when such care is reimbursed, a larger number of persons at risk for suicide will receive treatment. Such a change in perspective might also lead to a better integration of the separate systems of care that now exist–one for mental health, one for substance abuse, the other for primary and specialty health care.
Objective 3.4: By 2005, increase the proportion of those suicidal persons with underlying disorders who receive appropriate mental health treatment.
Research indicates that suicides are more likely early in the course of certain severe mental illnesses and that persons who have required hospitalization for severe mood disorders have a substantially increased lifetime risk of suicide compared to individuals with less severe illnesses. Yet, only a minority of persons with those mental or substance use disorders seek professional help.
The literature suggests that up to two-thirds of those who die by suicide are not receiving mental health or substance abuse treatment at the time of their death and that half had never seen a mental health professional (Jamison & Baldessarini, 1999; U.S. Department of Health and Human Services, 1999). Older people, for whom depression is quite prevalent and who have the highest rates of suicide in the U.S., are especially unlikely to utilize mental health services (Conwell, 1996; Hoyert et al., 1999). They tend to seek and receive health care in primary care settings, where it has been found that depression is frequently undiagnosed and untreated (Caine et al., 1996).
Ideas for Action
Develop public service announcements depicting consumers of mental health and substance abuse services as exhibiting responsible and appropriate health care behavior.
Members of some ethnic groups may also be reluctant to seek professional mental health care. Few treatment providers in the U.S. are knowledgeable about effective combinations of Western health care and culture- specific remedies that may enhance utilization of mental health services. Moreover, mental health services may not be available from persons who speak the language of individuals from particular ethnic groups or who understand the meaning of mental illness in the culture.
Persons from many ethnic and cultural groups encounter additional barriers to access, such as lack of health insurance. Since effective treatments now exist for the major depressive disorders, and since these disorders are implicated in such a high proportion of suicides, ensuring treatment for these illnesses should reduce the suicide rate. Mood disorders are very prevalent among individuals who complete suicide, with 36-70 percent of individuals having a mood disorder at the time of death (Barraclough, Bunch, Nelson, & Sainsbury, 1974; Henriksson et al., 1993; Foster, Gillespie, McClelland, & Patterson, 1999; Rich, Young, & Fowler, 1986).
Schizophrenia, certain personality disorders, and anxiety disorders in combination with other illnesses carry increased risk for suicide (Harris & Barraclough, 1997). An individual who suffers from one of these mental illnesses–especially if he or she has severe symptoms or a co-existing addictive disorder–is at increased risk of suicide (Angst et al., 1999).
Did You Know?
Many who make suicide attempts never seek professional care immediately after the attempt.
Reducing stigma related to mental illness and substance abuse will increase the number of persons from all groups who receive appropriate treatment for mental disorders associated with suicide.
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Arthur Buchanan
Out of Darkness & Into the Light
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